oligomet H&N cases

[Ray D. Ayshun]

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Mostly wondering people's paradigm when it comes to symptomatic oligomet cases. For instance, just saw a guy with a T3 true glottic cancer that's causing small volume hemoptysis, mild dyspnea and dysphagia also with what appear to be 2 lung mets. Wondering if, when symtomatic, people are starting with chemorads vs systemic therapy, or just palliative RT.

 

[thecarbonionangle]

1) start with systemic therapy then restage and if no wide progression, treat all sites “definitively”
2) treat definitively from start and SBRT both lung mets. Then do more adjuvant systemic therapy.

Systemic therapy will be important, of course!

 

[TheWallnerus]

Mostly wondering people's paradigm when it comes to symptomatic oligomet cases. For instance, just saw a guy with a T3 true glottic cancer that's causing small volume hemoptysis, mild dyspnea and dysphagia also with what appear to be 2 lung mets. Wondering if, when symtomatic, people are starting with chemorads vs systemic therapy, or just palliative RT.

Two lung Mets sound suspicious for a T3 glottic

You got tissue?

I don’t wanna act like a real doctor but in a fellow with dysphagia and dyspnea I think focal consolidation and aspiration pneumonia first, Mets second

 

[Ray D. Ayshun]

Two lung Mets sound suspicious for a T3 glottic

You got tissue?

I don’t wanna act like a real doctor but in a fellow with dysphagia and dyspnea I think focal consolidation and aspiration pneumonia first, Mets second

T3n2. Mets in upper lobe. But yes, will biopsy.

 

[evilbooyaa]

If significantly symptomatic, would treat definitively if considering oligomet paradigm.

If mildly symptomatic, treat with chemotherapy and then consolidate on back end.

For H&N we frequently end up treating definitively upfront then figure out the mets on the back end.

But yes, would biopsy to confirm mets before initiating therapy given even weekly chemo for H&N can cause ORR in met sites.

 

[TheWallnerus]

would treat definitively if considering oligomet paradigm

What a milquetoast paradigm as far as paradigms go

To qualify as a theory, a "paradigm" (or theory) must make good, reproducible predictions... else, we are just hand-waving

I'm (also) looking at you FLASH

 

[OTN]

Smoker? Could be a 2nd lung primary.

ChemoRT to the primary and regional lymphatics followed by immunotherapy indefinitely would be an option. Laryngeal chemoRT is easier to tolerate than oropharyngeal chemoRT, so even non-immunotherapy systemic treatment would be relatively easier to tolerate moving forward. I wouldn't chase levels Ib, Ia, etc, which would help spare salivary function.

Starting with systemic therapy would always be an option if lung mets are biopsy-proven, of course. If I were the patient, I would want more aggressive local therapy up front, to be honest, though. Systemic therapy for H+N ca is behind that of lung, breast, colorectal, etc. H+N primaries and nodes usually find a way to cause trouble without RT.

 

[Palex80]

The issue with H&N primary and one lung lesion is that‘s difficult to tell if the lung lesions are mets or second primary.
Even if you biopsy/resect it, it may not be conclusive if it turns out to be SCC. It could still be a NSCLC-SCC. NGS done both on H&N primary and lung-SCC-lesion can help (we‘ve done that a few times), but that means even more time lost. If primary is in oropharynx, P16 can help too.

 

[communitydoc13]

What a milquetoast paradigm as far as paradigms go

I haven't had a lot of luck with "oligometastatic" head and neck cancers.

Oligmetastatic EGFR+ lung? Hell yes

Oligometastatic Merkel? Yes

Oligometastatic endometrial where its climbing the RP nodal ladder and popping up in mediastinum or lung? yes

Oligometastatic colorectal? yes

Oligometastatic prostate? of course, particularly if hormone sensitive or newly refractory

But when head and neck mets out, I don't know. Those rare p16 positive OP cancers with bone mets? watch out, can kill quickly once metastatic. Those OC cancers? Good lord. They will fail everywhere and return and progress in your radiated neck as well.

Best luck I've had with oligometastatic H&N is with paranasal sinus tumors. Had several live for years.

But, dying of local disease in H&N is the worst. So I'm not dissing fairly aggressive local treatment.

 

[RadOncMegatron]

I haven't had a lot of luck with "oligometastatic" head and neck cancers.

Oligmetastatic EGFR+ lung? Hell yes

Oligometastatic Merkel? Yes

Oligometastatic endometrial where its climbing the RP nodal ladder and popping up in mediastinum or lung? yes

Oligometastatic colorectal? yes

Oligometastatic prostate? of course, particularly if hormone sensitive or newly refractory

But when head and neck mets out, I don't know. Those rare p16 positive OP cancers with bone mets? watch out, can kill quickly once metastatic. Those OC cancers? Good lord. They will fail everywhere and return and progress in your radiated neck as well.

Best luck I've had with oligometastatic H&N is with paranasal sinus tumors. Had several live for years.

But, dying of local disease in H&N is the worst. So I'm not dissing fairly aggressive local treatment.

I'm on board with this and would not do full dose chemoradiation. Especially if you have to extract teeth and put in a PEG. I'd offer palliative XRT followed by systemic therapy.

With that said, I understand why people would be more aggressive and understand why they would do so.

 

[Lamount]

I haven't had a lot of luck with "oligometastatic" head and neck cancers.

Oligmetastatic EGFR+ lung? Hell yes

Oligometastatic Merkel? Yes

Oligometastatic endometrial where its climbing the RP nodal ladder and popping up in mediastinum or lung? yes

Oligometastatic colorectal? yes

Oligometastatic prostate? of course, particularly if hormone sensitive or newly refractory

But when head and neck mets out, I don't know. Those rare p16 positive OP cancers with bone mets? watch out, can kill quickly once metastatic. Those OC cancers? Good lord. They will fail everywhere and return and progress in your radiated neck as well.

Best luck I've had with oligometastatic H&N is with paranasal sinus tumors. Had several live for years.

But, dying of local disease in H&N is the worst. So I'm not dissing fairly aggressive local treatment.

I have two metastatic p16+ cancer patients who I can think of off the top of my head who are doing really well. For one, I treated 4 lung mets in the first 1.5 years, and has been disease free for over a year (not on systemic therapy). The other got SBRT to one lung met 1 year ago and remains disease free on pembro

 

[jondunn]

I have two metastatic p16+ cancer patients who I can think of off the top of my head who are doing really well. For one, I treated 4 lung mets in the first 1.5 years, and has been disease free for over a year (not on systemic therapy). The other got SBRT to one lung met 1 year ago and remains disease free on pembro

The key IMO is only considering treatment after no progression on first line chemoIO.

 

[Ray D. Ayshun]

Right, but the ops original question was how do you approach the primary when nonemergently symptomatic? Still combi chemo? As said, larynx patients specifically, tend to do fine through chemorads, and concurrent cis is given at a "systemic" dose.

 

[jondunn]

Right, but the ops original question was how do you approach the primary when nonemergently symptomatic? Still combi chemo? As said, larynx patients specifically, tend to do fine through chemorads, and concurrent cis is given at a "systemic" dose.

Start chemoIO. Should respond.

 

[Lamount]

Right, but the ops original question was how do you approach the primary when nonemergently symptomatic? Still combi chemo? As said, larynx patients specifically, tend to do fine through chemorads, and concurrent cis is given at a "systemic" dose.

Personally, would do chemorads.

Local progression of H&N is awful and can drive mortality, even in metastatic patients.

 

[Ray D. Ayshun]

Lol, that's what I'll do. Tbh, I knew I could do whatever, just wanted to see how others approach, and what deets might push them one way or another. Wanted to strike up a non state of the field discussion.

 

[medgator]

Start chemoIO. Should respond.

Not quick enough in my experience.... If good ps, i try to do 40-50 in 15-20. Esp larynx with that airway concern

 

[communitydoc13]

I have two metastatic p16+ cancer patients who I can think of off the top of my head who are doing really well. For one, I treated 4 lung mets in the first 1.5 years, and has been disease free for over a year (not on systemic therapy). The other got SBRT to one lung met 1 year ago and remains disease free on pembro

Not scientific of me, just observation (although I have had others concur on this). Seems like there is a p16+ (which usually do very well) phenotype that mets to bone early and does very poorly. I have had isolated lung mets do well. (I also agree with @Palex80 that the non p16+ head and neck cancer patient is at very high risk for co-synchronous lung primary).

Even with lung squamous, I have seen a phenomenon in some patients (universally treated for early stage disease initially) of serial short interval progression of multiple lung squamous lesions. These may be treated as metastatic progression or as new primary, but I have had a couple patients, who were averse to systemic therapy, where I have treated with serial SBRT and who demonstrated no nodal or distant progression for years.

and concurrent cis is given at a "systemic" dose.

I am fine with chemorads here (or upfront chemo-IO if under close observation). But, I don't know if the "systemic dose" argument is valid for laryngeal CA. I believe the vast majority of benefit regarding concurrent chemotherapy in locally advanced head and neck has to do with locoregional control.

https://ascopubs.org/doi/10.1200/jco.2012.43.6097

 

[Ray D. Ayshun]

I am fine with chemorads here (or upfront chemo-IO if under close observation). But, I don't know if the "systemic dose" argument is valid for laryngeal CA. I believe the vast majority of benefit regarding concurrent chemotherapy in locally advanced head and neck has to do with locoregional control.

https://ascopubs.org/doi/10.1200/jco.2012.43.6097

right. my point was more centered around distant control, as exemplified by equivalent distant control 91-11, which is to say, it's more than just a radiosensitizer. Sure, you can argue that cis/5fu isn't a standard systemic therapy in larynx cancer, but its a platinum doublet. this gives me confidence the mets aren't being ignored if starting with chemorads.

 

[communitydoc13]

right. my point was more centered around distant control, as exemplified by equivalent distant control 91-11, which is to say, it's more than just a radiosensitizer. Sure, you can argue that cis/5fu isn't a standard systemic therapy in larynx cancer, but its a platinum doublet. this gives me confidence the mets aren't being ignored if starting with chemorads.

I got ya. I always read 91-11 the other way. Difference in distant outcomes not very different relative to even XRT alone. (~7% or so).

The post-op chemorads data also with basically zero impact on distant failures.

We definitely dismissed the long term OS results of this trial as a field!

 

[gmsquid]

I got ya. I always read 91-11 the other way. Difference in distant outcomes not very different relative to even XRT alone. (~7% or so).

The post-op chemorads data also with basically zero impact on distant failures.

We definitely dismissed the long term OS results of this trial as a field!

Hard to know about long term os given people with larynx cancer and postop HN ultimately die of other things. The only data that shows maybe an effect on distant Mets contain induction including studies from npx or the induction trials like paradigm and decide

 

[gmsquid]

Hard to know about long term os given people with larynx cancer and postop HN ultimately die of other things. The only data that shows maybe an effect on distant Mets contain induction including studies from npx or the induction trials like paradigm and decide

Also laryngectomy is excellent salvage.

 

[temujim]

Hard to know about long term os given people with larynx cancer and postop HN ultimately die of other things. The only data that shows maybe an effect on distant Mets contain induction including studies from npx or the induction trials like paradigm and decide

If you buy the meta-analyses, concurrent chemo has a ns ~1% decrease on mets, while induction chemo is ~4% decrease. Neither seem to drive an improvement in OS.

 

[jondunn]

Hard to know about long term os given people with larynx cancer and postop HN ultimately die of other things. The only data that shows maybe an effect on distant Mets contain induction including studies from npx or the induction trials like paradigm and decide

agree. this is why i favor starting with chemoIO (induction like multi agent dosing schedule) - you get the local response plus the intensified systemic control - before you come back and do something aggressive locally. if they progress distantly on first line therapy, unlikely we would have ever helped them.